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Date run 7/24/2017 9:29:03AR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/24/2017 <br /> Record Selection Criteria: Facility ID FA0002914 <br /> Make changeslcorrections in RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 11 SSN/Fed Tax ID <br /> Owner ID OW0001707 New Owner ID <br /> Owner Name PRB MANAGEMENT LLC <br /> Owner DBA TACO BELL <br /> Owner Address 4709 MANGELS BLVD <br /> FAIRFIELD, CA 945344175 <br /> Home Phone 707-864-2919 <br /> Work/Business Phone 707-864-2919 <br /> Mailing Address 4709 MANGELS BLVD <br /> FAIRFIELD, CA 94534-4175 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0002914 10181017 <br /> Facility Name TACO BELL#3560 <br /> Location 532 W HAMMER LN <br /> STOCKTON, CA 95210 <br /> Phone 209-477-9566 x <br /> Mailing Address 4709 MANGELS BLVD <br /> FAIRFIELD, CA 94534-4175 <br /> Care of PRB Management, LLC <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 08152043 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SHERRY DANIEL <br /> Title <br /> Day Phone 707-557-1198 <br /> Night Phone 209-473-9817 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002475 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name TACO BELL#3560 (Circle One) <br /> Account Balance as of 7/24/2017: $0.00 <br /> (Circle One) <br /> Transferto Active/Inactve <br /> Progrem/Element and Description Record ID Employee ID and Name Status New Omer? Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PRO162092 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A I D <br /> 1919-HMBP-0O2 Only Food Facility PR0520700 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513432 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0511144 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533254 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andvor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the parry identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes anclor Standards and State anNor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> EHD Staff: Date / / Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />